Methods to assess youth engagement in a text messaging supplement to an effective teen pregnancy program

Digital health interventions for all? Examining inclusivity across all stages of the digital health intervention research process

Digital interventions offer many possibilities for improving health, as remote interventions can enhance reach and access to underserved groups of society. However, research evaluating digital health interventions demonstrates that such technologies do not equally benefit all and that some in fact seem to reinforce a "digital health divide." By better understanding these potential pitfalls, we may contribute to narrowing the digital divide in health promotion. The aim of this article is to highlight and reflect upon study design decisions that might unintentionally enhance inequities across key research stages-recruitment, enrollment, engagement, efficacy/effectiveness, and retention. To address the concerns highlighted, we propose strategies including (1) the standard definition of "effectiveness" should be revised to include a measure of inclusivity; (2) studies should report a broad range of potential inequity indicators of participants recruited, randomized, and retained and should conduct sensitivity analyses examining potential sociodemographic differences for both the effect and engagement of the digital interventions; (3) participants from historically marginalized groups should be involved in the design of study procedures, including those related to recruitment, consent, intervention implementation and engagement, assessment, and retention; (4) eligibility criteria should be minimized and carefully selected and the screening process should be streamlined; (5) preregistration of trials should include recruitment benchmarks for sample diversity and comprehensive lists of sociodemographic characteristics assessed; and (6) studies within trials should be embedded to systematically test recruitment and retention strategies to improve inclusivity. The implementation of these strategies would enhance the ability of digital health trials to recruit, randomize, engage, and retain a broader and more representative population in trials, ultimately minimizing the digital divide and broadly improving population health.

The use, adherence, and evaluation of interactive text-messaging among women admitted to prevention of mother-to-child transmission of HIV care in Kenya (WelTel PMTCT)

BACKGROUND

To improve future mobile health (mHealth) interventions in resource-limited settings, knowledge of participants' adherence to interactive interventions is needed, but previous studies are limited. We aimed to investigate how women in prevention of mother-to-child transmission of HIV (PMTCT) care in Kenya used, adhered to, and evaluated an interactive text-messaging intervention.

METHODS

We conducted a cohort study nested within the WelTel PMTCT trial among 299 pregnant women living with HIV aged ≥ 18 years. They received weekly text messages from their first antenatal care visit until 24 months postpartum asking "How are you?". They were instructed to text within 48 h stating that they were "okay" or had a "problem". Healthcare workers phoned non-responders and problem-responders to manage any issue. We used multivariable-adjusted logistic and negative binomial regression to estimate adjusted odds ratios (aORs), rate ratios (aRRs) and 95% confidence intervals (CIs) to assess associations between baseline characteristics and text responses. Perceptions of the intervention were evaluated through interviewer-administered follow-up questionnaires at 24 months postpartum.

RESULTS

The 299 participants sent 15,183 (48%) okay-responses and 438 (1%) problem-responses. There were 16,017 (51%) instances of non-response. The proportion of non-responses increased with time and exceeded 50% around 14 months from enrolment. Most reported problems were health related (84%). Having secondary education was associated with reporting a problem (aOR:1.88; 95%CI: 1.08-3.27) compared to having primary education or less. Younger age (18-24 years) was associated with responding to < 50% of messages (aOR:2.20; 95%CI: 1.03-4.72), compared to being 35-44 years. Women with higher than secondary education were less likely (aOR:0.28; 95%CI: 0.13-0.64), to respond to < 50% of messages compared to women with primary education or less. Women who had disclosed their HIV status had a lower rate of non-response (aRR:0.77; 95%CI: 0.60-0.97). In interviews with 176 women, 167 (95%) agreed or strongly agreed that the intervention had been helpful, mainly by improving access to and communication with their healthcare providers (43%).

CONCLUSION

In this observational study, women of younger age, lower education, and who had not disclosed their HIV status were less likely to adhere to interactive text-messaging. The majority of those still enrolled at the end of the intervention reported that text-messaging had been helpful, mainly by improving access to healthcare providers. Future mHealth interventions aiming to improve PMTCT care need to be targeted to attract the attention of women with lower education and younger age.

Text Messaging Intervention for Mental Wellness in American Indian and Alaska Native Teens and Young Adults (BRAVE Study): Analysis of User Engagement Patterns

Background

Many American Indian and Alaska Native (AI/AN or Native) communities express concern about high rates of suicide and poor mental health. Technology-based health interventions that nurture resilience, coping skills, connectedness, and help-seeking skills may be an effective strategy for promoting health and wellbeing among AI/AN youth. The Northwest Portland Area Indian Health Board designed the BRAVE intervention for AI/AN youth. BRAVE is delivered via SMS text messaging and includes role model videos, mental wellness strategies, links to culturally relevant resources, and social support from family and friends.

Objective

The aim of this study is to explore system data from the BRAVE intervention to determine patterns of user engagement and differences in psychosocial outcomes based on the number of clicks on BRAVE content.

Methods

The BRAVE study included 1030 AI/AN teens and young adults nationwide (15 to 24 years old). The message series in the BRAVE and STEM study arms included 3 to 5 SMS text messages per week, featuring 1 role model video and 1 image per week. Messages were sent out via Mobile Commons (Upland Software Inc), a mobile messaging provider that supports text, picture, and video SMS.

Results

Of the 509 participants in the original BRAVE analysis, 270 had sufficient data to analyze user engagement, with at least 1 trackable click on a study SMS text message. Of the 270, 184 (68.1%) were female, 50 (18.5%) were male, and 36 (13.3%) selected another gender category. The average participant was 20.6 years old, with a minimum and maximum age of 15 and 26 years. Most participants had relatively low engagement measured by the number of clicks (median 2; mean 3.4), although others clicked message content as many as 49 times. Users engaged most frequently with the YouTube-based content (viewing 1 of 7 role model videos), with 64.8% (175/270) of total clicks coming from the role model videos, and earlier episodes receiving the highest number of clicks. Most baseline psychosocial measures were not significantly associated with the number of links clicked. However, help-seeking behavior was highly significant (P<.001), with a rate ratio of 0.82 (0.73, 0.92), indicating that each 1-unit increase in help-seeking score at baseline was associated with an 18% decrease in the expected number of study content clicks.

Conclusions

This is the first study to set initial standards for assessing user engagement in an mHealth intervention. Our work underscores the feasibility of exploring the impact of engagement on intended outcomes, allowing for more precise exploration of the dose-response relationship that may be realized through these low-touch interventions that offer promising potential for reaching high numbers of program participants.

Trial Registration

ClinicalTrials.gov NCT04979481; https://clinicaltrials.gov/ct2/show/NCT04979481

An Enhanced SMS Text Message-Based Support and Reminder Program for Young Adults With Type 2 Diabetes (TEXT2U): Randomized Controlled Trial

Background

Clinic attendance, metabolic control, engagement in self-management, and psychological health are suboptimal in young-onset (age of onset <40 years) type 2 diabetes.

Objective

We examined the effectiveness of an enhanced SMS text message–based support and reminder program in improving clinic attendance, metabolic control, engagement in self-management, and psychological health in young-onset type 2 diabetes.

Methods

A 12-month, parallel-arm, randomized controlled trial comparing an enhanced, semipersonalized SMS text message–based intervention (incorporating 1-8 supportive and/or informative text messages per month) against standard care was conducted in a specialized clinic for young adult type 2 diabetes. The primary outcome was maintenance of 100% attendance at scheduled quarterly clinical appointments. Secondary outcomes included (1) metabolic indices, (2) pathology and self-monitored blood glucose (SMBG) data availability, and (3) psychosocial well-being.

Results

A total of 40 participants were randomized, and 32 completed their 12-month study visit. The average participant age was 32.7 (SD 5.1) years, 50% (20/40) were male, and baseline glycated hemoglobin A_1c (HbA_1c) was 7.3% (SD 1.9%) (56 mmol/mol, SD 20). A higher proportion of the intervention group achieved 100% attendance (12/21, 57%, vs 5/19, 26%, for the control group); Kaplan-Meier analysis demonstrated significantly greater cumulative attendance in the intervention group (P=.04). There were no between-group differences in HbA_1c, BMI, lipids, or availability of pathology and SMBG data. Odds of recording an improvement in the Diabetes Empowerment Scale–Short Form score were higher in the intervention group at 6 months (odds ratio [OR] 4.3, 95% CI 1.1-17), with attenuation of this effect at study end (OR 3.1, 95% CI 0.9-11). Program acceptability was high; >90% of participants would recommend the program to new patients.

Conclusions

An enhanced SMS text message–based support and reminder program doubled scheduled clinic attendance rates for patients with young-onset type 2 diabetes. The program was highly acceptable and provided early support for patient empowerment but had no significant effect on measures of metabolic control or self-management.

Trial Registration

Australian and New Zealand Clinical Trials Registry (ACTRN12618000479202); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373579

Using Technology to Support Expectant and Parenting Youth through Case Management: Lessons Learned in the Field

Introduction

The Support. Empower. Learn. Parenting Health Initiative (SELPHI) provides expectant and parenting youth ages 16–24 in Philadelphia with supports to improve educational, social, and economic outcomes to shape their health and the health of their children. Phone, text, video-based, and social media communication technology is built in to SELPHI’s program design to facilitate case management and connect clients to a broad referral network. Given the novelty of using information and communication technology (ICT) in case management, the reported lessons learned seek to give providers a specific and nuanced picture of ICT in case management.

Methods

In its initial 6-month implementation period, SELPHI’s five case managers, called Navigators, served 59 clients. Data from feedback surveys and case records were collected from clients and Navigators. Data included client demographic characteristics, needs assessment, and contact records to inform continuous quality improvement (CQI).

Results

ICT’s benefits included having multiple ways to connect to difficult-to-reach clients, the ability to be more responsive to clients, and the flexibility to address scheduling and transportation barriers. ICT’s challenges are related to Navigators’ boundary setting, limitations on rapport building, and data security considerations. CQI data are presented to illustrate the lessons learned. Text messages were the most prevalent ICT; phone calls were most successful in engaging clients. Clients’ ICT preferences differed by purpose of communication.

Discussion

Findings suggest that programs should understand the nuances of client contact preferences. To maximize the benefits of ICT, programs must develop or adapt protocols based on preference and purpose of communication.

Recruiting and Engaging American Indian and Alaska Native Teens and Young Adults in a SMS Help-Seeking Intervention: Lessons Learned from the BRAVE Study

This paper shares lessons learned recruiting and engaging participants in the BRAVE study, a randomized controlled trial carried out by the Northwest Portland Area Indian Health Board and the mHealth Impact Lab. The team recruited 2330 American Indian/Alaska Native (AI/AN) teens and young adults nationwide (15-24 years old) via social media channels and text message and enrolled 1030 to participate in the 9 month study. Teens and young adults who enrolled in this study received either: 8 weeks of BRAVE text messages designed to improve mental health, help-seeking skills, and promote cultural pride and resilience; or 8 weeks of Science Technology Engineering and Math (STEM) text messages, designed to elevate and re-affirm Native voices in science, technology, engineering, math and medicine; and then received the other set of messages. Results indicate that social media channels like Facebook and Instagram can be used to recruit AI/AN teens and young adults. Retention in this study was high, with 87% of participants completing both the BRAVE and STEM intervention arms. Lessons learned from this process may help teen and young adult-serving organizations, prevention programs, policy makers, researchers, and educators as they support the next generation of AI/AN change makers.

A Randomized Controlled Trial of a Texting Intervention to Maintain Sexual Risk Reduction with Clients Among Female Sex Workers in Tijuana and Ciudad Juarez, Mexico

Mobile phone technology may help sustain reductions in HIV/STI transmission risk behaviors among female sex workers (FSWs). We examined the efficacy of a text messaging intervention designed to maintain behavioral improvements in safer sex practices among 602 FSWs in Tijuana and Ciudad Juarez, Mexico. We hypothesized that FSWs who received brief risk reduction counseling and theory-based safer sex maintenance text messages over a 24-month period would have fewer incident HIV/STIs and report greater maintenance of safer sex practices compared to FSWs who received counseling and texts on maintaining general health. Theory-based texts did not change the odds of becoming infected with HIV/STIs in either study site. However, they did lead to significant, sustained protected sex in Tijuana. Theory-based text messaging interventions may help sustain reductions in sexual risk behavior among FSWs.Trial Registration Clinical Trials.gov. Identifier: NCT02447484.

Utility of Short Message Service (SMS) for Remote Data Collection for HIV in Low- and Middle-Income Countries

PURPOSE OF REVIEW

Short message system (SMS) communication is widespread in low- and middle-income countries (LMICs), and may be a viable approach to address challenges with in-person data collection for HIV-related research and monitoring and evaluation. We reviewed the literature to characterize potential benefits and challenges with using SMS for remote data capture, including examples from HIV and sexual and reproductive health.

RECENT FINDINGS

In our review, we found that studies that have used SMS to capture sensitive, self-reported data found this was an acceptable and feasible strategy, and may reduce social desirability bias of self-reported data; but studies are limited. Shared phones and privacy concerns have been described as challenges, but can be addressed with enhanced security features. Response rates to SMS surveys varied significantly by topic, population, and setting. SMS may improve generalizability and precision of health and behavior data for HIV in research and programs, but use in LMICs is limited. SMS systems should be carefully designed to overcome potential implementation hurdles.

Feasibility of Assessing Economic and Sexual Risk Behaviors Using Text Message Surveys in African-American Young Adults Experiencing Homelessness and Unemployment: Single-Group Study

Background

Text messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings.

Objective

This study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys.

Methods

We conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback.

Results

Overall, 65% (n=11/17) of the participants responded to at least one text message survey compared with 35% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64%) of the responders were women. The majority (n=4/6, 67%) of nonresponders were men. An average of 7.6 participants (69%) responded in a given week. Response rates among ever responders ranged from 64% to 82% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90% of all questions), ranging from 72% to 100%. An average of 6.4 participants (84%) answered all 14 text message questions in a given week, ranging from 57% to 100%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives.

Conclusions

Longitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors.

Trial Registration

ClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871

Feasibility, Acceptability, and Process Indicators for Guy2Guy, an mHealth HIV Prevention Program for Sexual Minority Adolescent Boys

PURPOSE

Guy2Guy is one of the first mHealth HIV prevention programs for sexual minority boys aged 14-18 years, evaluated nationally. Here, we examine the program's feasibility and acceptability and explore participants' feedback about program content and components intended to invigorate program engagement.

METHODS

Guy2Guy was tested in a randomized controlled trial of 302 youth assigned to either the intervention or an attention-matched control group. At 3-month follow-up, participants completed a survey that included questions about feasibility and acceptability. Focus groups were conducted with a subset of intervention participants (n = 45) to further understand their program experience.

RESULTS

The protocol and program appeared to be feasible: 94% completed the 3-month follow-up survey. The intervention also appeared to be acceptable: 93% of intervention participants said they somewhat or strongly agreed that they liked the program. Although ∼20% boys agreed that the program sent too many messages, only 10% said they stopped reading the messages by the end. Focus group participants were largely enthusiastic about program content and generally appreciated receiving information and skills-building messages that talked about HIV risk reduction. Some indicated a desire for more content that addressed condom negotiation. Program engagement components, particularly the weekly "level up" quiz, also were generally well received.

CONCLUSIONS

Sexual minority boys are willing to engage in Guy2Guy, an intensive, multiweek sexual health intervention via text messaging, and most would recommend the program to their friends.

Exploring the Use of Technology for Sexual Health Risk-Reduction among Ecuadorean Adolescents

BACKGROUND

There is a lack of sexual health knowledge and resource access among youth in Latin America, along with rising rates of teenage pregnancy and STD transmission.

OBJECTIVE

To determine baseline sexual health knowledge and the acceptance of a technology based sexual health risk-reduction program among Ecuadorean adolescents.

METHODS

We used mixed methods to determine the sexual health knowledge and practices, and technology use among 204 adolescents from two schools in Cumbayá and Lumbisí, Ecuador. Quantitative data was collected through surveys and qualitative through single-gender focus groups.

FINDINGS

Nearly every participant (96.6%) expressed interest in a sexual health education program using technology and social media. A majority of participants indicated that they consulted parents (58.3%) regarding sexual health questions. Only a few participants had access to physicians outside of appointments (3.9%), and most desired more sexual health information (87.3%). Although approximately one-quarter of participants were sexually active (27%), most lacked baseline knowledge regarding contraceptives and STDs. Facebook (91%) and WhatsApp (53%) were the most frequently used and requested social media for an educational program. Students indicated a strong desire to be involved in the design stages of a sexual health risk-reduction program, rather than use a pre-established program.

CONCLUSIONS

There is strong interest in a technology based sexual health risk-reduction program through Facebook and WhatsApp, which could establish communication between health providers and Ecuadorian youth to disseminate health information and answer private inquiries. Findings from this study, the first of its kind among South American adolescents, introduces a novel idea: involving participants from initial design stages of a text-messaging health education program. Future studies should focus on engaging families as well as physicians' willingness to participate.Implications and Contributions: This paper is the first acceptability study of a technology based sexual health risk-reduction program among low-income South American adolescents. Findings enhance understanding of pregnancy and STD prevention interventions by demonstrating participants' desire for self-design and implementation, and highlight their importance through a lack of baseline adolescent sexual health knowledge.

Impact of time perspectives on texting intervention to reduce HIV/STI transmission among female sex workers in Tijuana and Ciudad Juarez, Mexico

Text messages may sustain post-counseling gains in behavioral improvements and reduce HIV/STI incidence. However, their effectiveness may depend on the messages' time perspective and characteristics of the individual. We evaluated the impact of time perspective on a text messaging intervention designed to maintain improvements in safer sex practices among drug-using and non-drug-using female sex workers (FSWs) in Tijuana (n = 141) and Cd. Juarez (n = 129), Mexico. FSWs received the efficacious Mujer Segura intervention, and were randomized to receive safer sex maintenance text messages with either a short-term or future-oriented time perspective. The outcome was HIV/STI incidence rate over 6-month follow-up. In Tijuana, combined HIV/STI incidence density was lower among FSWs in the FUTURE group (31.67 per 100 py) compared to women in the SHORT-TERM group (62.40 per 100 py). Conversely, in Cd. Juarez, HIV/STI incidence density was lower (although non-significant) among FSWs in the SHORT-TERM group (19.80 per 100 py) compared to those in the FUTURE group (35.05 per 100 py). These findings suggest that future-oriented text messages may sustain post-counseling improvements in sexual risk behavior among FSWs, but findings may vary by FSWs' characteristics (e.g., drug use), and by region and context.

Insights From a Text Messaging-Based Sexual and Reproductive Health Information Program in Tanzania (m4RH): Retrospective Analysis

BACKGROUND

Many mobile health (mHealth) interventions have the potential to generate and store vast amounts of system-generated participant interaction data that could provide insight into user engagement, programmatic strengths, and areas that need improvement to maximize efficacy. However, despite the popularity of mHealth interventions, there is little documentation on how to use these data to monitor and improve programming or to evaluate impact.

OBJECTIVE

This study aimed to better understand how users of the Mobile for Reproductive Health (m4RH) mHealth intervention engaged with the program in Tanzania from September 2013 to August 2016.

METHODS

We conducted secondary data analysis of longitudinal data captured by system logs of participant interactions with the m4RH program from 127 districts in Tanzania from September 2013 to August 2016. Data cleaning and analysis was conducted using Stata 13. The data were examined for completeness and "correctness." No missing data was imputed; respondents with missing or incorrect values were dropped from the analyses.

RESULTS

The total population for analysis included 3,673,702 queries among 409,768 unique visitors. New users represented roughly 11.15% (409,768/3,673,702) of all queries. Among all system queries for new users, 46.10% (188,904/409,768) users accessed the m4RH main menu. Among these users, 89.58% (169,218/188,904) accessed specific m4RH content on family planning, contraceptive methods, adolescent-specific and youth-specific information, and clinic locations after first accessing the m4RH main menu. The majority of these users (216,422/409,768, 52.82%) requested information on contraceptive methods; fewer users (23,236/409,768, 5.67%) requested information on clinic location. The conversion rate was highest during the first and second years of the program when nearly all users (11,246/11,470, 98.05%, and 33,551/34,830, 96.33%, respectively) who accessed m4RH continued on to query more specific content from the system. The rate of users that accessed m4RH and became active users declined slightly from 98.05% (11,246/11,470) in 2013 to 87.54% (56,696/64,765) in 2016. Overall, slightly more than one-third of all new users accessing m4RH sent queries at least once per month for 2 or more months, and 67.86% (278,088/409,768) of new and returning users requested information multiple times per month. Promotional periods were present for 15 of 36 months during the study period.

CONCLUSIONS

The analysis of the rich data captured provides a useful framework with which to measure the degree and nature of user engagement utilizing routine system-generated data. It also contributes to knowledge of how users engage with text messaging (short message service)-based health promotion interventions and demonstrates how data generated on user interactions could inform improvements to the design and delivery of a service, thereby enhancing its effectiveness.

Text Messaging, Teen Outreach Program, and Sexual Health Behavior: A Cluster Randomized Trial

OBJECTIVES

To consider whether Youth All Engaged! (a text message intervention) intensified the effects of the adolescent pregnancy prevention Teen Outreach Program (control) for youths.

METHODS

In this trial performed in Denver, Colorado, from 2011 to 2014, we randomized 8 Boys & Girls Clubs each of 4 years into 32 clubs per year combinations to ensure each club would serve as a treatment site for 2 years and a control site for 2 years. Control intervention consisted of the Teen Outreach Program only. We enrolled 852 youths (aged 14-18 years), and 632 were retained at follow-up, with analytic samples ranging from 50 to 624 across outcomes. We examined program costs, and whether the intervention increased condom and contraceptive use, access to care, and pregnancy prevention.

RESULTS

Control program costs were $1184 per participant, and intervention costs were an additional $126 per participant (+10.6%). There were no statistically significant differences in primary outcomes for the full sample. Hispanic participants in the intervention condition had fewer pregnancies at follow-up (1.79%) than did those in the control group (6.72%; P = .02).

CONCLUSIONS

Youth All Engaged is feasible, low cost, and could have potential benefits for Hispanic youths.

Lactation Advice through Texting Can Help: An Analysis of Intensity of Engagement via Two-Way Text Messaging

Rates of breastfeeding initiation and duration among women who attend the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are dramatically lower than nonparticipants. Innovative solutions are needed to improve breastfeeding rates in this population. The Lactation Advice through Texting Can Help (LATCH) study was one such approach, designed to augment and reinforce the WIC breastfeeding peer counseling process. The purpose of the present study was to examine engagement via two-way text messaging in a sample of women attending the WIC breastfeeding peer counseling program and enrolled in LATCH. The objectives were to: (1) describe text message engagement in the context of LATCH; and (2) assess the association between engagement variables and exclusive breastfeeding status. Text messaging data were first coded qualitatively by two independent researchers and engagement variables created. An analysis of engagement was conducted using descriptive statistics for normally distributed data and binary logistic regression. In the multivariable model, intensity of engagement during the first 2 weeks post partum was the single strongest predictor of exclusive breastfeeding status. LATCH is an innovative intervention designed to enhance the capacity of breastfeeding peer counselors and holds much potential for improving exclusive breastfeeding rates in this population.